Gastrointestinal Complications of Warfarin: Spontaneous Intramural Hematoma and Intussusception of the Jejunum

Park, Woo Chan; Kim, In Chul

Abstract

Hemorrhage is the main complication in patients with anticoagulant therapy. We experienced two cases of spontaneous intramural hematoma of the small bowel as gastrointestinal complications of the oral anticoagulant warfarin. In case 1, a 35-year-old woman who had been receiving warfarin and acetyl salicylic acid (ASA) for valvular heart disease came to emergency room in a shock state with complaints of epigastric pain, nausea, and vomiting for 4 days. The prothrombin time (PT) was prolonged to over 60 seconds, and a radiologic examination revealed an intestinal obstruction with an intussusception of the small bowel. An exploro- laparotomy showed multiple intramural hematomas of the small bowel and an intussusception in the jejunum without causative findings. Segmental resection was performed, and the patient recovered without any problems. In case 2, a 54-year-old woman was admitted because of diffuse abdominal pain for 4 days. She had had a mitral valve replacement due to mitral stenosis 5 years earlier. Warfarin administration had been continued postoperatively with regular checks of the PT. Physical examination revealed tenderness and rebound tenderness on the left upper quadrant of abdomen and the PT was 41.5 seconds (INR 5,9). On exploration, the proximal jejunum just distal to Treitz ligament was discolored to purple, and an extensive intramural hematoma was noted. However there was no obvious cause of hematoma, or other abnormal findings. Segmental resection was performed. The postoperative course was uneventful. A review of the literature on hemorrhagic complications of the small bowel in anticoagulant therapy, the most common site was the jejunum and diagnosis was made based on history of receiving anticoagulants and gastrointestinal symptoms. Additionally, in obscure cases to diagnose, a barium study of small bowel is recommended for diagnosis of intramural hematoma. Sometimes, sonography or CT scan is helpful in its diagnosis. Conservative mangement is sufficient, but surgery should be considered when surgical indications, such as strangulation, are identified or when the patient's condition is not improved or becomes worse with conservative care.